Health

Planning families

The combined Pill is a very effective and convenient method of contraception. When used according to instructions, less than one in 100 women will get pregnant in a year of use.

THE majority of couples want to plan how many children they have and when to have them. The best form of family planning (contraception) for individual(s) is an important decision, with contraceptive needs changing with the passage of time.

A method suitable for teens or twenties may not be suitable in the thirties or forties. The choice of a contraceptive depends on age, health status, lifestyle, whether the person is in a permanent relationship with a partner, religious and cultural beliefs, and whether the family has been completed.

Contraception is a shared responsibility, but it is the girl or woman who is left holding the baby if an unplanned pregnancy results. Pregnancy can result from a single act of sexual intercourse.

The oral contraceptive (“the Pill”) is a safe and reliable contraceptive method used by millions of women worldwide. The combined Pill contains oestrogens and progestogens and the “Mini-Pill” contain progestogens only.

The combined Pill is very effective and convenient to use. When used according to instructions, less than one in 100 women will get pregnant in a year of use. However, the reality is that up to five in 100 typical users will get pregnant in a year of use because of various reasons.

Different combined Pills

The combined Pill contains both oestrogen and progestogen that are similar to the ones made by the ovaries. It prevents eggs from being released by the ovaries. Without an egg, pregnancy cannot result.

The Pill also thickens the cervical mucous, thereby preventing sperm swimming up into the uterus, and also thins the lining of the uterus, thereby decreasing the chances of a fertilised egg implanting into the uterus.

There are three main types:

Monophasic – Each tablet has the same amount of hormone and is taken for 21 days. It is not taken the next seven days.

Phasic – There are two or three sections of different coloured tablets in each pack with each section having different amounts of hormones and are taken for 21 days. Nothing is taken the next seven days.

Daily – There are 21 to 24 tablets that contain hormones, with four to seven tablets that are placebo and are taken daily without a break between packs.

The advantages far outweigh the risks in almost all women. The Pill does not interrupt sex and it keeps the periods regular, shorter and lighter. This reduces the likelihood of anaemia, in which there is a reduction in the haemoglobin which transports oxygen in the blood. It relieves menstrual cramps or pains and symptoms of pre-menstrual syndrome (PMS). It also reduces the risk of ectopic pregnancy (a potential life threatening condition in which the pregnancy is sited outside the uterine cavity).

The Pill has been shown to protect women against non-cancerous breast disease and cancers of the ovary, endometrium (lining of the uterine cavity) and colon. It can reduce acne and may protect against pelvic inflammatory disease.

However, some Pill users experience side effects, which are not usually harmful, and most of which disappear within three months. They include nausea (many find that taking the pill with food or just before bed time helpful), fluid retention, breast tenderness, altered sex drive (libido) and mood swings.

If these do not go away after a few months, it may help to change to a different Pill.

Breakthrough bleeding or spotting is not uncommon in the initial months of usage. It can also increase the blood pressure.

There are some risks associated with the Pill, but they are small. It is not suitable for smokers aged 35 years and above, those who have stopped smoking for less than a year and are aged 35 years and above, those who have or had high blood pressure, blood clots in the legs, heart attacks, stroke, severe migraine, diabetes with complications, diabetes for more than 20 years, gall bladder disease or some liver tumours, those who are pregnant or obese and those taking certain medicines.

Studies suggest that Pill users have a slightly increased likelihood of being diagnosed with breast cancer compared to those not taking the Pill. This likelihood returns to normal within a decade of stopping the Pill. However, the Pill provides some protection against cancers of the endometrium, ovary and colon.

There is no evidence that the Pill causes weight gain.

Taking the Pill

Before commencing on the Pill, it is advisable to consult a doctor, who will determine if it is a suitable contraceptive method for an individual after a health and lifestyle evaluation. This will include questions about smoking, whether there are certain medical conditions present, and whether any medicines are being taken.

A physical examination will usually suffice. However, certain tests may be carried out depending on the individual’s health status.

Most women can start the Pill at any time in their menstrual cycle. However, there is special guidance if one had just given birth or suffered miscarriage.

Depending on when the Pill is started in the menstrual cycle, additional contraception may be needed.

If the Pill is started on the first day of the period, there will be instant protection against pregnancy. Commencing the Pill up to the fifth day of the period also provides instant protection against pregnancy unless the menstrual cycle is short, i.e. every 23 days or less. In such a situation, additional contraception will be required until after a week of taking the Pill.

If the Pill is started on any other day of the menstrual cycle, there will not be instant protection against pregnancy and additional contraception will be required until after a week of taking the Pill.

If the Pill is started 21 days after giving birth or a miscarriage, there will be instant protection against pregnancy. If it is started later, additional contraception will be required until after a week of taking the Pill.

As the Pill can reduce the flow of milk, it is recommended that a different contraceptive method be used until breastfeeding ceases.

The Pill has to be taken every day at about the same time. Each pack should be started on the same day of the week as the start of the previous pack.

The Pill comes in packs of 21 or 28 pills. After completing a pack, which has 21 pills, one will have to wait seven days before starting a new pack.

During the week when no pill is taken, the period will flow. If the pack contains 28 pills, one does not have to stop taking the pills. The last few pills in the 28 pills pack do not contain hormones. They are there to make taking the Pill easier. During the week that the last pills are being taken, the period will flow.

Back-up contraception, i.e. condom, cap, diaphragm or spermicide, is not required if the Pill is taken properly.

The Pill does not protect against sexually transmitted infections. If there is any possibility of sexually transmitted infection (STI), then the use of condoms will help protect against STIs.

Missed pills

Most women forget to take a pill every now and again. It is considered late when it is taken after the usual time. It is missed when it is more than 24 hours since the time it should have been taken.

The chances of getting pregnant after missing a pill(s) depend on when they are missed and how many are missed.

Missing one pill or starting a new pack a day late is not a problem as there is still protection against pregnancy (contraceptive cover). However, missing two or more pills or starting the pack more than 48 hours late may affect contraceptive cover, especially if it involves the seven day pill-free break.

The missed pill should be taken as soon as one remembers. The next pill should be taken at the normal time. It is alright to take two pills in the same day.

If one forgets to take two or more pills, back up contraception should be used and advice sought from the doctor.

If some pills are missed, there may be some spotting or light bleeding even if the missed pills are taken. This side effect is not harmful.

If one forgets to take some of the last seven pills of a 28 day pill packet, there is no need to worry. The missing pills can be thrown away and a pill taken daily until the packet is empty. The new pack is then started on the same day of the week as the start of the previous pack.

The Pill interacts with other medicines, which reduces its effectiveness. They include antibiotics like rifampicin, which is used to treat tuberculosis, and enzyme inducers, like medicines used to treat epilepsy and HIV as well as St John’s wort, a herbal remedy.

Alternative or additional contraception would be advised for women taking such medicines.

Myths about the Pill

Much has been said or written about the Pill that are not evidence based. Some of the common myths and facts include the following:

Myth – Taking the Pill is risky.

Fact – The risks from smoking or road traffic accidents are higher than the Pill, from which benefits outweigh the risks in most women. However, the Pill is not advisable in women with certain risk factors (as listed above).

Myth – The Pill causes cancer.

Fact – Most studies report that the Pill does not increase the risk of cervical or breast cancer. The risk of ovarian cancer is reduced by 50% in women who have used the Pill for five years, and this protective effect lasts for about 15 years after stopping the Pill.

The risk of endometrial cancer is reduced by 50% if the Pill is taken for more than one year and the protection persists for 15 years after stopping.

Myth – Taking a break from the Pill every now and then is advisable.

Fact – There is no health benefit from taking a break, which may increase the chances of an unwanted pregnancy.

The Pill is a very effective and safe way to prevent an unwanted pregnancy. It is easy to use, convenient and reversible. It is only effective if taken as prescribed and does not protect against sexually transmitted infections.

It has other important health benefits, some of which continue even after its use has stopped. The benefits of the Pill outweigh the risks in almost all women.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.